Continuing Contradictions in US Global “Family Planning” Policies

On his third day in office, President Donald Trump issued an executive order that prohibits reproductive health NGOs that receive US family planning assistance from providing abortion services, information, or referrals, or participating in advocacy to liberalize abortion laws. Since its introduction by President Reagan’s administration in 1984 at the United Nations Conference on Population and Development in Mexico City, this policy been reinstated by Republican presidents (George H. Bush and George W. Bush) and rescinded by Democratic presidents (Bill Clinton and Barack Obama). In other words, it represents a way of signaling, during the earliest days of each new administration, the government’s stance on global and domestic abortion politics.

Organizations that receive US family planning assistance are required to certify in writing that they will not use their own funds to engage in abortion-related activities and services prohibited by the policy. Reproductive health advocates have dubbed President Reagan’s 1984 Mexico City Policy “the Global Gag Rule” for its silencing effect on abortion research, services, and advocacy by international NGOs. Despite the policy’s goal to reduce abortion, evidence suggests that declines in abortion rates have stalled in developing countries. The anti-abortion stance of the 1984 Mexico City Policy belies an earlier interest on the part of the US government in deploying abortion as a mechanism of population control in developing countries. Until the early 1970s, the US government significantly invested in the research, development, and global distribution of not only contraception but also abortion technologies.

The current iteration of the “Global Gag Rule” in many ways represents the culmination of a long history of the US government’s involvement in the field of global population and development, in which domestic debates about women’s access to abortion and contraception have been inextricably intertwined with foreign policy related to reproductive health.

By the mid-1950s, to respond to the perceived problem of overpopulation in developing countries, population experts in the Ford and Rockefeller Foundations, the Population Council, and Pathfinder International were actively engaged in global family planning programming and research. In contrast, US foreign policy remained silent on the issue of population until the mid-1960s. In 1965, the same year that the US Supreme Court legalized contraceptive use for married couples in its Griswold v. Connecticut ruling, President Lyndon B. Johnson characterized population control as a matter of national security in his State of the Union address. As countries decolonized in the global South, US policymakers grew increasingly concerned that the strain on resources caused by overpopulation in newly sovereign nations would render them sympathetic to socialism. By the late 1960s, the USAID had officially incorporated family planning into development aid and was actively funneling money to organizations such as International Planned Parenthood Federation (IPPF) and the United Nations Fund for Population Activities (UNFPA) that provided family planning services in developing countries.

During the early 1970s, the Office of Population of the United States Agency for International Development (USAID) supported the manufacture and distribution of a syringe technology now known as the Manual Vacuum Aspiration (MVA) syringe. In 1973, the same year that the US Supreme Court legalized abortion upon request for American women, Congress passed the Helms Amendment to the Foreign Assistance Act, which prohibited the “promotion of abortion as a form of family planning.”

Under the Helms Amendment, federal funds could not be used to procure abortion services, drugs, or devices. It signaled the growing influence of a domestic anti-abortion movement, galvanized by Roe v. Wade, that aimed to curb the application of federal funds to abortions at home and abroad.

In response to these new restrictions, the USAID delegated the manufacture and distribution of the MVA device to NGOs such as the International Pregnancy Advisory Service (now known as Ipas). By 1978 approximately 175,000 MVA devices had been distributed to developing countries through Ipas, IPPF and the International Research Fertility Program (IRFP) for the purpose of menstrual regulation, a euphemism for abortion [1-3].

Despite the USAID’s continuing commitment to family planning as an essential development strategy, President Reagan introduced increasingly anti-abortion policies into foreign development plans during the early 1980s. The USAID continued to donate contraceptives and support family planning training for health workers, but stopped funding biomedical research on abortion and training of medical providers in abortion techniques. Additionally, the USAID began to promote natural family planning methods such as the fertility awareness method, also known as the rhythm or calendar method.

In 1984, the US delegation to the United Nations Population and Development conference in Mexico City unveiled the Reagan administration’s population policy. While the US had taken a strong “population control” stance since the mid-1960s, at this conference the US no longer perceived high fertility as an impediment to economic development. Instead, US delegates identified neoliberal reform as the solution to underdevelopment. Within the health sector, this meant scaling back state investments in primary health care recommended by the Alma Ata Declaration of 1978 and increasing user fees for health services.

Although the US reaffirmed its commitment to family planning in the Mexico City Policy, it categorically precluded funding for abortion services, referral or counseling, even in countries where abortion was legal. Additionally, in contrast to previous USAID language on contraceptive use as a matter of voluntarism and informed choice among women and couples, the 1984 policy framed contraception in terms of “preserving maternal and child health” and “meeting the interests of families” [3].

In other words, this policy prioritized access to contraception for mothers as a matter of family health rather than women’s sexual and reproductive health and choice.

Not surprisingly, the 1984 Mexico City Policy did not achieve its goal of reducing abortion in countries receiving US aid. To the contrary, evidence suggests that in response to family planning service cutbacks and clinic closures among NGOs affected by the policy, undesired pregnancies and abortions increased in these countries. A 2011 study of 20 African countries shows that the odds of abortion more than doubled during periods when the policy was in effect [4]. In Ghana, abortion increased among low-income and rural women and child health outcomes declined under the policy [5].

The US is one of the most generous donors of global family planning assistance, providing up to $575 million in 40 countries [6].

The Mexico City Policy hinders the USAID’s ability to donate contraceptives and support health providers in developing countries where access to family planning is key to preventing unwanted pregnancy and reducing maternal mortality. Additionally, it infringes on the sovereignty of national health authorities to address public health matters as they see fit [7].

In Nepal, for example, complications of unsafe abortion account for up to 50% of maternal mortality. In 2002, the government legalized abortion to address the public health problem of unsafe abortion. When the Family Planning Association of Nepal (FPAN), the country’s largest family planning provider, refused to comply with the Mexico City Policy, it lost up to $400,000 worth of contraceptives donated by the USAID. To continue operations in its national network of clinics, FPAN had to introduce user fees and lay off health workers. Given that FPAN provides between 25 to 30% of Nepal’s reproductive health services, including contraception, infertility diagnosis and treatment, gynecological exams, and legal abortion, the Global Gag Rule directly restricts Nepalese women’s access to reproductive health care [8].

When President George W. Bush reinstated the Mexico City Policy in 2001, he exempted various services, programs, and institutions, including post-abortion care (emergency treatment for abortion complications), hospitals, governments, and the President’s Emergency Plan for AIDS Relief (PEPFAR). The 2017 policy makes no such exceptions and goes even further by extending to all organizations receiving US global health assistance, which totals approximately $9 billion in 60 countries [6]. Under President Trump, the Mexico City Policy could potentially threaten the ability of NGOs, governments, and hospitals in developing countries to treat life-threatening complications of abortion and diagnose and treat infectious disease such as HIV, malaria, tuberculosis, Zika, and Ebola.

There is no fiscal, geopolitical, or public health rationale for the “Global Gag Rule.” The 1973 Helms Amendment already prevents the application of US tax dollars towards abortion-related services or devices abroad.

It has not contributed to declines in abortion in countries that receive US family planning assistance. In fact, while abortion rates have declined significantly in developed countries since 1990, they remain the same in much of the developing world [9]. The aim of the “Global Gag Rule” is simple: to restrict women’s reproductive autonomy. In this sense, ironically, it echoes rather than disrupts the population control logics of the Cold War era. The Mexico City Policy has simply shifted, and in its latest iteration, expanded the mechanisms through which women’s bodies are controlled.